急性重症冠心病应用急诊冠状动脉旁路移植术治疗的临床体会

目的：针对南昌大学第三附属医院2003年7月～2013年12月的16例急性重症冠心病患者进行急诊冠状动脉旁路移植术（ECABG）治疗的临床体会。方法16例急性重症冠心病患者中16例患者均在术前常规放置IABP,均在体外循环下进行急诊冠状动脉旁路移植术治疗。结果急性心梗10例,其中伴心源性休克5例,PCI失败5例;顽固性心绞痛3例;陈旧性心梗合并室壁瘤2例;陈旧性心梗合并二尖瓣关闭不全1例。16例患者在急诊冠状动脉旁路移植术治疗早期死亡2例,术后低心排4例,肺部感染3例,切口愈合不良1例,14例患者均痊愈出院。结论在对急性重症冠心病患者采取急诊冠状动脉旁路移植术治疗时,要提高急诊冠状动脉旁路移植术治疗成功率,应充分重视急诊冠状动脉旁路移植术术前患者合并症处理、术中要强化患者心肌保护,并选择适合患者的血管移植材料及术后心功能维护,这样才能提高急诊冠状动脉旁路移植术治疗的临床效果。     

Coronary angiography and coronary artery revascularisation rates in public and private hospital patients after acute myocardial infarction

OBJECTIVE: To determine the rates of coronary angiography or coronary artery revascularisation procedures in patients with acute myocardial infarction (AMI) managed in private versus public hospitals. DESIGN: Case record linkage analysis of data from the Victorian Inpatient Minimum Dataset for admissions for AMI in the 12 months after the index admission. SETTING: Victorian acute care hospitals from July 1995 to December 1997. PATIENTS: Victorian residents aged 15-85 years admitted to hospital with AMI. MAIN OUTCOME MEASURES: Rates of coronary angiography or coronary artery revascularisation procedures after AMI. RESULTS: Compared with public patients in public hospitals, patients with AMI managed in private hospitals were more likely to undergo coronary angiography (rate ratio [RR], 2.17; P< 0.001; 95% CI, 2.06-2.29), coronary angioplasty or stenting (RR, 3.05; P<0.001; 95% CI, 2.82-3.31), and coronary artery bypass grafting (RR, 1.95; P<0.001; 95% CI, 1.79-2.14). Once coronary angiography had been performed, patients in private hospitals were more likely to undergo angioplasty or stenting (RR, 1.94; P<0.001; 95% CI, 1.79-2.11), but were only marginally more likely to undergo coronary artery bypass grafting (RR, 1.17; P<0.001; 95% CI, 1.07-1.28). CONCLUSIONS: In Victoria, management of patients with acute myocardial infarction is influenced by the public or private status of the patient, and by whether management occurs in private or public hospitals. Patients are more likely to undergo coronary angiography and coronary artery revascularisation procedures in private hospitals.     

Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients.

OBJECTIVE--This study examines the differences in the rates of coronary artery bypass grafting (CABG) between white and black Medicare patients. DESIGN--This is a cross-sectional study with data from the 1986 Health Care Financing Administration hospital claims records on all Medicare patients, the 1988 update of the Bureau of Health Professions area resource file, and the 1985 Census Bureau's county population estimates file. SETTING--Data are from all Medicare patients in the United States in 1986. MAIN OUTCOME MEASURES--Sex- and age-adjusted CABG rates for whites and blacks over the age of 65 years were computed for each of 50 states and 305 Standard Metropolitan Statistical Areas (SMSAs). RESULTS--Nationally the CABG rate was 27.1 per 10,000 for whites (40.4 for white men and 16.2 for white women), but only 7.6 for blacks (9.3 for black men and 6.4 for black women). Racial differences were greater in the Southeast, particularly in nonmetropolitan areas, than in other regions. Neither white nor black SMSA rates were associated with the rate of admission for acute myocardial infarction (an indication of the amount of coronary artery disease). White rates, but not black rates, were associated with the number of thoracic surgeons per 100,000 people. CONCLUSIONS--For patients insured by Medicare, race is strongly associated with CABG rates, and this association is greater for men than for women and greater in the Southeast than in other parts of the country. Physician supply may relate to the CABG rates for whites.     

Long-term cardiac prognosis following noncardiac surgery. The Study of Perioperative Ischemia Research Group.

OBJECTIVE--To determine the long-term (2-year) cardiac prognosis of high-risk patients undergoing noncardiac surgery and to determine the predictors of long-term adverse cardiac outcome. DESIGN--Prospective cohort study. Historical, clinical, and laboratory data were collected during the in-hospital period, and at 6 months, 1 year, and 2 years following surgery. Data were analyzed using proportional hazards models. SETTING--University-affiliated Veterans Affairs medical center. POPULATION--A consecutive sample of 444 patients with or at high risk for coronary artery disease who had undergone elective noncardiac surgery and were discharged from the hospital in stable condition. MAIN OUTCOME MEASURES--Cardiac death, myocardial infarction, unstable angina, progressive angina requiring coronary artery bypass graft surgery or coronary angioplasty, and new unstable angina requiring hospitalization. RESULTS--Forty-seven patients (11%) had major cardiovascular complications during a 728-day (median) follow-up period: 24 had cardiac death; 11, nonfatal myocardial infarction; six, progressive angina requiring coronary artery bypass graft surgery or coronary angioplasty; and six, new unstable angina requiring hospitalization. Thirty percent of outcomes occurred within 6 months of surgery and 64% within 1 year. Five independent predictors of long-term outcome were identified. Three predictors reflected the preexisting chronic disease state: (1) the presence of known vascular disease (hazard ratio, 6.1; 95% confidence interval [CI], 2.5 to 15.0; P less than .0001); (2) a history of congestive heart failure (hazard ratio, 5.0; 95% CI, 2.0 to 12.0; P less than .0005); and (3) known coronary artery disease (hazard ratio, 3.7; 95% CI, 1.7 to 8.0; P less than .0007). Two predictors reflected acute postoperative ischemic events: (1) myocardial infarction/unstable angina (hazard ratio, 20; 95% CI, 7.5 to 53.0; P less than .0001) and (2) myocardial ischemia (hazard ratio, 2.2; 95% CI, 1.1 to 4.3; P less than .03). Patients surviving a postoperative in-hospital myocardial infarction had a 28-fold increase in the rate of subsequent cardiac complications within 6 months following surgery, a 15-fold increase within 1 year, and a 14-fold increase within 2 years (95% CI, 5.8 to 32; P less than .00001). Seventy percent of all long-term adverse outcomes were preceded by in-hospital postoperative ischemia that occurred at least 30 days (median, 282 days) before the long-term event. The development of congestive heart failure or ventricular tachycardia (without ischemia) during hospitalization was not associated with adverse long-term outcome. CONCLUSIONS--The incidence of long-term adverse cardiac outcomes following noncardiac surgery is substantial. At increased risk are patients with chronic cardiovascular disease; at highest risk are patients with acute perioperative ischemic events. We conclude that survivors of in-hospital perioperative ischemic events, specifically myocardial infarction, unstable angina, and postoperative ischemia, warrant more aggressive long-term follow-up and treatment than is currently practiced.     

Differences in prognostic factors and outcomes between women and men undergoing coronary artery stenting

CONTEXT: Women with coronary artery disease (CAD) are believed to have a higher risk for adverse outcomes than men after conventional coronary interventions. The increasing use of coronary stenting has improved the outcome of patients undergoing coronary interventions, but little is known about the nature of outcomes in men vs women after this procedure. OBJECTIVE: To examine whether there are sex-based differences in prognostic factors and in early and late outcomes among CAD patients undergoing coronary stent placement. DESIGN, SETTING, AND PATIENTS: Inception cohort study, at 2 tertiary referral institutions in Germany. Consecutive series of 1001 women and 3263 men with symptomatic CAD who were treated with stenting between May 1992 and December 1998. Patients who underwent stenting in the setting of acute myocardial infarction were excluded. MAIN OUTCOME MEASURE: The combined event rates of death and nonfatal myocardial infarction, assessed at 30 days and 1 year after stenting and compared by sex. RESULTS: Compared with men, women undergoing coronary stenting were significantly older (mean age, 69 vs 63 years) and more likely to present with diabetes, arterial hypertension, or hypercholesterolemia. Women had less extensive CAD, a less frequent history of myocardial infarction and better preserved left ventricular function than men. Women presented an excess risk of death or nonfatal myocardial infarction only during the early period after stenting: the 30-day combined event rate of death or myocardial infarction was 3.1% in women and 1.8% in men (P =.02) and the multivariate-adjusted hazard ratio (HR) for women was 2.02 (95% confidence interval [CI], 1.27-3.19). At 1 year, the outcome was similar for both women and men (combined event rate for women, 6.0%, and for men, 5.8% (P =.77); multivariate-adjusted HR for women, 1.06 [95% CI, 0.75-1.48]). There was a sex difference in the prognostic value of baseline characteristics: the strongest prognostic factors were diabetes in women and age in men. CONCLUSIONS: The results of this study indicate that 1-year outcomes of women with CAD undergoing coronary artery stenting are similar to those of men. Despite the similarity in outcomes, there are several sex-specific differences in baseline characteristics, clinical course after the intervention, and relative weight of prognostic factors. JAMA. 2000;284:1799-1805.     

Reperfusion and revascularization strategies for coronary artery disease in women.

OBJECTIVE--One third of all deaths in women in the United States each year are attributable to coronary heart disease. Gender differences exist in the course and management of patients with coronary heart disease. Few randomized trials have been conducted in women to evaluate effective therapeutic strategies. With the aim of developing rational approaches to women with coronary heart disease, we review gender-related outcomes with coronary revascularization and reperfusion therapies. DATA SOURCE--English-language journal articles and reviews on the subject of women with coronary heart disease or gender-specific responses to coronary heart disease management, from 1970 through 1992, identified through MEDLINE searching. STUDY SELECTION--Selected studies included only randomized controlled trials for topics related to thrombolysis, and articles considered to contribute significantly to the topic of women with coronary artery disease in the case of angioplasty and coronary artery bypass grafting. DATA EXTRACTION--Two reviewers participated in extracting the data with the aim of presenting a balanced and comprehensive review of the subject. DATA SYNTHESIS--Thrombolysis in acute myocardial infarction reduces mortality in men and women, although women may have a reduced mortality benefit compared with men. Angioplasty and the newer interventional devices result in greater procedural morbidity but similar if not better long-term outcomes in women. Women may have a greater mortality rate than men with coronary artery bypass surgery, although studies suggest that outcome after bypass surgery may depend more on coronary size and preoperative risk factors than on gender itself. CONCLUSIONS--The existence of gender differences in the course of coronary heart disease and response to revascularization and reperfusion strategies suggests the need for unique clinical approaches to the female patient with coronary heart disease and stresses the importance of developing randomized trials that enroll adequate numbers of women and that are designed to answer gender-specific questions.     

女性非ST段抬高急性冠脉综合症患者临床特点和冠状动脉病变特点分析

目的探讨女性非ST段抬高急性冠脉综合症患者的临床特点和冠状动脉病变特点,为临床积极治疗提供参考。方法选择310例在我院经临床资料、冠状动脉造影确诊的女性NSTEACS患者为研究组,同期在我院经冠状动脉造影确诊的男性NSTEACS患者370例为对照组。分别对其临床特点和冠状动脉病变的支数、部位、狭窄类型及程度进行比较。结果⑴与男性相比,女性NSTEACS患者临床表现类型以急性心肌梗死更多见,典型的心绞痛症状和心电图缺血性表现较少,住院期间心功能不全发生率高于男性,吸烟史少、糖尿病史多,血脂异常以TG升高和HDL-C降低更为突出。低血红蛋白血症、高尿酸血症、高同型半胱氨酸血症和社会心理因素对女性的影响也较男性更为明显。而家族史、高血压病史与男性相比无明显差别。⑵与男性相比,女性NSTEACS患者冠状动脉单支病变明显低,而以多支病变明显,侧枝循环形成高于男性;受累血管以前降支最为常见,但两组相比无显著性差异,其次为右冠状动脉,与男性相比有显著性差异;病变血管的狭窄类型女性组以B、C型病变为多,但无统计学差异;病变血管的狭窄程度以gensini积分计算,女性组以中度升高比率为主,且明显高于男性。结论女性非ST段抬高急性冠脉综合症的临床表现类型以急性心肌梗死更多见,临床症状不如男性典型,TG升高和HDL-C降低更为突出,高尿酸血症、高同型半胱氨酸血症等新的危险因素在其发病中发挥了更重要的作用。女性冠脉病变以多支病变为多,侧枝循环形成高于男性。狭窄程度较男性重。     

Graft patency in off-pump and conventional coronary artery bypass grafting for treatment of triple vessel coronary disease

Inanattempttoavoidthedeleteriouseffectsofcardiopulmonarybypass (CPB) ,off pumpcoronarybypasssurgeryhasrecentlybeenrediscoveredandrefined Overthepastdecade ,theuseofoff pumporbeating heartcoronaryarterybypass (OPCAB)surgeryhassincebecomemorepopularandwidelyused Intriplevesseldisease ,accesstothelateralandposteriorwallvesselstofacilitatecompleterevascularizationevolved ,accompaniedbytechnicaladvancesintheinstrumentationforstabilizationoftheheart Multiplepreviousauthorshavereportedaseriesofoff…     

升主动脉钙化冠心病合并心肌桥12例临床分析

目的：分析升主动脉钙化冠心病合并心肌桥的外科治疗效果。方法：对12例升主动脉钙化冠心病合并心肌桥患者施行冠状动脉旁路移植术和心肌切开术,12例患者均存在不同程度的升主动脉钙化,术中将血管桥近端吻合在降主动脉上,对于较浅的心肌桥在非体外循环下行心肌切开术,而对于走形于心肌深部的肌桥,采用体外循环下冠状动脉旁路移植术;血管段同时合并狭窄及肌桥时,在心肌桥远侧的部位进行冠状动脉旁路移植术。结果：所有患者均手术顺利,无严重并发症,术后随访未出现心脏不良反应。结论：升主动脉钙化冠心病合并心肌桥者选择适当的手术方式可取得令人满意的近期效果,其远期疗效还有待于进一步观察。     

Association between inflammatory mediators and angiographic morphologic features indicating thrombus formation in patients with acute myocardial infarction

Background Inflammatory mechanisms had played an important role in the occurrence and prognosis of acute myocardial infarction, inflammatory mediators was associated with adverse outcomes of acute myocardial infarction. This study tested the hypothesis that in the acute phase of myocardial infarction with ST-segment elevation, neutrophil count and high-sensitivity C-reactive protein are predictive of angiographic morphologic features that indicate thrombus formation in the infarct-related artery. Methods This retrospective study included 182 consecutive patients with acute myocardial infarction and ST-segment elevation. Patients were assigned to a thrombus-formation group （n=77） and a non-thrombus-formation group （n=-106）. All patients had a Killip＇s classification 〈3 and onset 〈12 hours prior to presentation. All the cases were going to undergo coronary angiography, including primary percutaneous coronary intervention, simple coronary angiography, or thrombolysis in a coronary artery （or arteries） or coronary artery bypass graft（s）. Blood samples for measurement of high-sensitivity C-reactive protein and for routine blood laboratory studies were collected prior to coronary angiography. Results The levels of high-sensitivity C-reactive protein, total leukocyte counts, neutrophil counts, and neutrophil/ lymphocyte ratios were substantially higher in the thrombus-formation group than in the non-thrombus-formation group patients （for each, P 〈0.05）. Stepwise Logistic regression analyses identified high-sensitivity C-reactive protein, neutrophil count, and neutrophil/lymphocyte ratio as independent predictors of thrombus formation in the infarct-related artery （for each, P 〈0.05）. Conclusions In patients with acute myocardial infarction levels of high-sensitivity C-reactive protein are predictors to higher neutrophil counts, neutrophil/lymphocyte ratio, and ndicate thrombus formation     

冠状动脉旁路移植术56例报道

目的总结分析56例冠状动脉旁路移植术(CABG)的临床经验.方法 1999年10月～2003年11月,我院对56例冠心病患者行冠状动脉旁路移植术.左主干病变4例,单支病变3例,双支病变13例,三支病变36例.全部胸骨正中切口,42例在体外循环下进行,17例在非体外循环下进行.乳内动脉搭桥26根,大隐静脉搭桥128根,人均搭桥2.8支.结果全组死亡1例,其余患者痊愈出院,术后心绞痛完全消失或明显减轻.随访2～48个月效果良好.结论 CABG是治疗冠心病的一种安全有效的方法,合理选择病人,妥善围手术期管理,术中良好的心肌保护及不断提高外科操作技术是提高手术成功率的关键.     

梗死前心绞痛在未行血运重建的急性心肌梗死患者中的临床意义

目的 探讨在未行血运重建的急性心肌梗死患者中有无梗死前心绞痛对患者预后是否有影响. 方法将未能及时行急诊再灌注治疗且后期因各种原因未能行择期PCI或CABG术的122例AMI患者分为梗死前心绞痛组（A组）和无梗死前心绞痛组（B组）,比较两组QRS积分、心肌酶学峰值、LVEF及起病1个月内病死率情况. 结果 A组QRS积分、心肌酶学峰值及起病1个月内病死率明显低于B组（P ＜ 0.05）,但A组LVEF明显高于B组（P ＜ 0.05）. 结论梗死前心绞痛可以对心梗患者心肌产生保护作用,从而在其后发生AMI时能减轻心肌损伤,对其预后有益.通过询问AMI前有无心绞痛发作史,对判断患者预后有参考价值.     

主动脉内球囊反搏在抢救危重心脏病患者中的应用

目的：观察应用主动脉内球囊反搏（IABP）治疗危重心脏病患者的效果。方法：对20例危重心脏病患者并发心源性休克及低心排血量综合征的患者应用IABP治疗,其中6例冠状动脉旁路移植术（cABG）,2例冠状动脉旁路移植术加室壁瘤切开折叠术,1例主动脉瓣加二尖瓣置换术,1例主动脉瓣置换加冠状动脉移植术（Bentall）加全弓置换术,10例急性心肌梗死（AMI）并发心源性休克,其中5例发生心脏骤停并进行心肺复苏术（CPR）。结果：10例顺利撤离IABP,抢救成功率50％。结论：IABP是抢救危重心脏病患者的一种有效治疗措施,应该及早使用。     

冠状动脉搭桥术——五例报告

我院自1986年开展冠状动脉搭桥术,已完成5例。其中4例是陈旧性心肌梗塞和梗塞后心绞痛,1例是不稳定型心绞痛,迫近型心肌梗塞。结合术前造影及术中所见:4例为单枝血管病,行单枝搭桥术,其中1例有左室壁瘤行室壁瘤切除术。例5为三枝血管病变行三枝搭桥术。1例因与手术无关原因于术后第二天死亡,余4例均已康复出院。术后心绞痛症状消失,心电图改善。本文对手术适应症,术式及疗效进行讨论。     

冠状动脉支架植入术治疗急性心肌梗塞39例

目的：小结采用直接冠状动脉支架植入术治疗39例急性心肌梗塞患者的中期效果。方法：接受介入治疗距胸痛发作的平均时间为4．2h。经股劝脉采用Judkins技术完成冠状动脉造影及支架植入术,在38例患者42支血管共植入55个支架,1例患者仅行右冠状动脉球囊成形术。结果：术后即刻TIMI血流3级者36例（92．3％）,TIMI血流2级者3例（7．7％）。术中6例（15．4％）在便塞相关动脉开通后出现心室颤动,1例（2．6％）死于继发性心室颤动。术后平均随访8．1个月,除1例死于术后2周非梗塞相关动脉择期支架植入术外,无心肌梗塞、做外科冠状动脉搭桥术和再次做梗塞相关动脉介入治疗的病例。结论：直接冠状动脉支架术可以迅速获得便塞相关动脉TIMI3级血流,中期效果良好。     

冠状动脉旁路移植术后近期治疗效果的危险因素分析

目的探讨影响冠状动脉旁路移植术（CABG）近期治疗效果的危险因素,为冠心病患者的术前和术后处理提供参考依据。方法回顾性分析我院2000年8月至2009年10月收集的172例CABG患者的临床及相关资料,对可能导致术后近期死亡的影响因素进行回顾性多因素分析。结果 172例患者中,早期死亡21例,死亡率12.2%。围手术期心梗、术前心功能不全、左室室壁瘤、体外循环下手术对CABG术后近期死亡的影响差异有统计学意义（P〈0.05）。结论围手术期心梗、术前心功能不全、左室室壁瘤、体外循环下手术是影响CABG术后近期死亡的危险因素。     

冠状动脉旁路移植术后监护和处理(附105例报告)

目的分析总结105例冠状动脉旁路移植术后监护和处理的临床经验.方法回顾性总结105例冠状动脉旁路移植术的临床资料.结果住院死亡4例,死亡率3.8%.其他并发症包括:低心排(5.71%),室性心律失常(12.38%),围术期心梗(1.90%),房颤(20.00%),低氧血症(20.95%),高血糖(35.23%),伤口感染(1.90%),出血(0.95%),精神障碍(2.86%).随访3月～3年,3例再发严重心绞痛.结论冠状动脉旁路移植术是治疗冠心病的有效方法,术后监护和处理是保证手术成功的关键之一.     

不同年龄段急性心肌梗死患者介入治疗的预后分析

目的：探讨不同年龄段急性心肌梗死患者介入治疗的预后。方法：选取行介入治疗的急性心肌梗死患者120例,按照不同年龄段分为中青年组（<60岁）和老年组（≥60岁）各60例,对其预后进行回顾性分析。结果：两组患者介入治疗前梗死相关动脉（前降支、回旋支、右冠状动脉）分布比较,差异无统计学意义。老年组患者多支冠脉病变发生率明显高于中青年组患者,差异具有统计学意义。中青年组手术并发症,住院天数及心功能恢复情况均优于老年组,差异具有统计学意义;中青年组住院期间心血管事件发生率与老年组比较,差异无统计学意义。中青年组术后1年MACE发生率明显低于老年组,差异具有统计学意义;中青年组病死率和老年组比较,差异无统计学意义。结论：年龄是影响急性心肌梗死介入治疗预后的危险因素,中青年急性心肌梗死患者预后优于老年急性心肌梗死患者。对于老年急性心肌梗死患者应及时进行介入治疗,采取有效治疗措施,同样也能有利于预后恢复。     

冠状动脉旁路移植术治疗重症冠心病25例临床分析

目的总结本科1999年6月~2006年12月行重症冠心病患者施行CABG 25例临床经验。方法25例患者中合并陈旧性心肌梗死6例,急性心肌梗死5例,合并二尖瓣和/或主动脉瓣病变5例,心肌梗死后巨大室壁瘤2例,左室功能重度减退(EF<30%)6例。20例在中低温体外循环(CPB)下进行CABG手术,同时行瓣膜置换术5例。5例在非CPB下进行搭桥。结果本组术后早期死亡3例,其中围手术期心肌梗死2例,胸骨哆开后呼吸功能衰竭1例。另并发肺部感染4例,经积极抗感染,加强营养支持后好转。术后静脉桥分支出血心包填塞1例,二次手术止血后好转。结论要提高重症患者的CABG手术的成功率,必须重视术前合并症的处理,术中加强心肌的保护,无合并其他心内手术者,尽可能行OPCABG,要选择适宜的血管移植材料,重视吻合技巧的训练。     

不停跳冠脉搭桥心肌保护技术在瓣膜疾病合并冠心病手术中的应用

  目的   介绍不停跳冠脉搭桥心肌保护技术在瓣膜疾病合并冠心病手术中的应用。   方法   观察2017年1月—2020年7月就诊于中国科学技术大学附属第一医院心脏外科的瓣膜病合并冠心病的149例患者,应用不停跳冠脉搭桥心肌保护技术行瓣膜置换合并冠脉搭桥术的手术效果和相关并发症。对于搭桥+主动脉瓣膜/双瓣膜置换术,经左、右冠状动脉开口直接灌注+经静脉桥血管灌注,然后行心脏瓣膜置换术,缝合主动脉切口+静脉桥血管吻合。对于搭桥+二尖瓣膜置换手术,将静脉桥血管吻合至主动脉,降温阻断后,行主动脉根部灌注和二尖瓣膜置换。   结果   149例手术患者中,主瓣+搭桥49例,二尖瓣+搭桥83例,双瓣+搭桥17例,单支冠脉病变需搭桥54例,2支病变55例,3支病变40例。术后住院期间死亡10例,术后有4例发生永久性脑卒中,有28例发生急性肾功能不全需透析治疗,有18例机械通气时间>24 h。   结论   对于冠心病合并瓣膜病的患者,在冠状动脉搭桥合并瓣膜手术中应用不停跳冠脉搭桥心肌保护技术具有操作简单、手术效果满意、术后并发症少及临床效果满意等优点。